National Journal of Research in Community Medicine. Vol.6. Issue 3. Jul.-Sep.-2017(217-222) ISSN - Print: 2277 – 1522, Online: 2277 – 3517

Original Research Article

Knowledge and practice regarding Diarrheal Diseases and Drinking Water Usage in district, South .

Sudhir Ben Nelson1*, Priya R Panicker2, Lakshmi Nandakumar3, Krishnaveni Malaichamy3

Date of Submission: 18.05.2017 Date of Acceptance: 07.07.2017

Authors: Corresponding Author: 1. Assistant Professor, 2. Junior Resident, &3. Intern, Dr. Sudhir Ben Nelson Department of Community Medicine, Sree Assistant Professor, Department of Community Mookambika Institute of Medical Sciences, Medicine, Sree Mookambika Institute of , Tamilnadu, India. Medical Sciences, Kulasekaram, Tamilnadu, India. Pin: 629001 Email: [email protected]

Abstract

Introduction: Acute diarrheal diseases account for about 8% of deaths among under 5 children in India. Approximately 88% of diarrheal diseases are attributed to unsafe water supply, inadequate sanitation and hygiene. Proper knowledge about diarrhea and its prevention is essential for the people to practice adequate control measures. Proper water usage and handling practice also play an important role in control of diarrheal / water borne diseases. Objectives: to assess 1) knowledge and practice regarding diarrheal diseases and 2) the drinking water practices among the population of Arumanai panchayat of in South India. Material & Methods: A cross sectional study was done

among households of Arumanai panchayat of Kanyakumari district between September and November 2015. 150 households that have been residing in the area for > 6 months were included. Data was collected using a pretested semi-

structured questionnaire Results: Among the respondents, 26.7% (40) believed microorganisms to be a cause of diarrhea, while88% believed that boiling renders the water safe for drinking purposes. Only 50.7% had prepared Oral Rehydration Solution (ORS) during the last episode of Diarrhea. 40.7% of the respondents washed their hands with soap and water before eating food and only 24% did it after defecation. Half of the households used covered well as their source of drinking water & 97.3% had a toilet at home. 86% boil water used for drinking purposes but only 27.3% boil water for 10 minutes. 44% household do not clean their well frequently & 20.7% use chlorination. Conclusions: The degree of knowledge and practice regarding diarrheal diseases and the drinking water practices was found to be inconsistent. The knowledge and use of ORS is better than what is seen in many studies done in India. The community needs further Behaviour change communication including training on proper treatment of water.

Keywords: Diarrhea, ORS, Hand Hygiene, Drinking water, Boiling deaths worldwide. More than 80 percent of these deaths occur in sub-Saharan Africa and South Asia.1 INTRODUCTION In India, acute diarrheal diseases accounts for about 8% Diarrhea and water borne diseases are the leading cause of deaths in under 5 years age group. During the year of mortality and morbidity in developing countries.1Acute 2011, about 10.6 million cases with 1,293 deaths were diarrhea is rivalled in importance only by respiratory reported in India.4 India also has the highest estimates of infection, as a cause of morbidity on a worldwide scale. under 5 mortality due to diarrhea in the world.1 Despite When the WHO initiated the Diarrheal Diseases Control the success of various national programs like Universal Programme in 1980, approximately 4.6 million children Immunization Program, Child Survival and Safe used to die each year due to dehydration caused by Motherhood (CSSM), Reproductive and Child Health diarrhea.2Diarrhea is still a major killer of children under (RCH), Integrated Management of Neonatal and 5 years, although its toll has dropped by a third over the Childhood Illnesses (IMNCI) and Reproductive, past decade, from 1.2 million deaths in 2000 to 0.7 Maternal, Neonatal, Adolescent and Child Health million in 2011.3It now causes about 11 percent of child

217 Diarrheal Diseases and Drinking Water Usage. Sudhir Ben Nelson et.al. Click here for more articles: www.commedjournal.in National Journal of Research in Community Medicine. Vol.6. Issue 3. Jul.-Sep.-2017(217-222) ISSN - Print: 2277 – 1522, Online: 2277 – 3517 programmes (RMNCH+A), the proportional mortality practices that need special focus. It will also help in rate of diarrhea in India still remains high.5 finding out any other health or public work actions required in the community. Hence this study was Diarrhea is also a leading cause of death during conducted to assess knowledge and practice regarding emergencies and natural disasters. Displacement of diarrheal diseases and the drinking water practices among population into temporary overcrowded shelters is often the population of Arumanai panchayat of Kanyakumari associated with polluted water sources, inadequate district in South India. sanitation, poor food hygiene practices and malnutrition- all of which affect the spread and severity of diarrhea.4 MATERIAL AND METHODS

Safe drinking water has been recognized as a basic Study setting: Kanyakumari district in the state of element of ‘Primary health care’ by the World Health Tamilnadu, is the southernmost district of mainland India. Assembly as part of ‘Health for All by 2000’.4 Water In receives significant rainfall during both monsoon intended for human consumption should be both safe and seasons of India and is comparatively rich in water wholesome and in adequate amounts for fulfilling the resources. Arumanai Panchayat of Kanyakumari district is requirements of a family or a community. This has been a town panchayat with a population of 16,283 coming defined as water that is -free from pathogenic agents, free from 4,236households. The overall Literacy rate is from harmful chemical substances, pleasant to the taste, 90.5%.9A cross sectional study was conducted among the i.e., free from color and odour; and usable for domestic population of Arumanai Panchayat for a period of 2 purposes.4 months from September to November 2015.

Water is said to be polluted or contaminated when it does Sampling: A pilot testing of the questionnaire was done not fulfill the above criteria. Water pollution is a growing among the households and proportion of households with hazard in many developing countries owing to overuse, one episode of diarrhea in past 5 years was obtained as decreased groundwater reserves and irresponsible human 55%. Sample size of 145 houses was arrived at using the activity. Without ample and safe drinking water, basic formula n=4pq/d2, where the above proportion is health care services cannot be provided to the community. considered as p, q= 1-p and d is the permissible error (taken as 15% of p). This was rounded off to 150 samples. Approximately 88% of diarrheal diseases are attributed to The sample households were selected from the panchayat 6 unsafe water supply, inadequate sanitation and hygiene. household list. Arumanai panchayat has 15 separate Water sources and sanitation facilities have an important locations/villages. 10 households were selected from each influence on the health of household members, especially area by simple random sampling. children.7 Unsafe drinking water is a major problem, especially in rural areas. Even when a drinking water Inclusion criteria: Households whose residents have supply is provided, unhygienic water handling practices been residing in the study area for more than 6 months result in contamination and thereby produce diarrheal and had a respondent aged more than 18 years at the time diseases, especially in the vulnerable groups of children of data collection were included in the study. Exclusion and the elderly. Personal hygiene especially hand washing criteria: Households where the available adult is the most important factor in preventing diarrheal respondent could not answer questions coherently were disease transmission. Lack of toilets and the practice of excluded from the study. open air defecation in rural areas also cause illness & death among children.8 Data collection: Data was collected using a pretested semi-structured questionnaire administered to the The methods taken to prevent diarrheal diseases are respondents in the local language after obtaining informed mainly focused at the household level. Thus without written consent. It contained questions on basic proper action by the family diarrheal diseases cannot be characteristics of the respondents, knowledge about cause brought under control. There are several misconceptions of Diarrheal diseases, perceptions about diarrheal and varied perceptions about diarrheal diseases among lay diseases& actions taken when somebody has diarrhea. people, especially in villages. Proper knowledge about Questions on Oral Rehydration Solution (ORS) & Hand diarrhea and its prevention is essential for the people to hygiene were included. Details about the drinking water practice adequate control measures. Water usage and sources, human waste disposal, water storage & handling, handling practice also play an important role in knowledge about water contamination & its prevention, transmission of diarrheal / water borne diseases. A study actions taken to purify the water were also asked. If the incorporating both these aspects is still relevant in any selected household could not be included in the study, the state of India. Information from the community will help adjacent house was selected and the respondents were the local public health personnel in assessing the need for included after obtaining informed consent. Data collected health education and the aspects of knowledge and was entered into Microsoft Excel 2010 version. Data was

218 Diarrheal Diseases and Drinking Water Usage. Sudhir Ben Nelson et.al. Click here for more articles: www.commedjournal.in National Journal of Research in Community Medicine. Vol.6. Issue 3. Jul.-Sep.-2017(217-222) ISSN - Print: 2277 – 1522, Online: 2277 – 3517 analysed using SPSS (trial version 20) and frequencies lime & ginger syrup.(Table 2) During the last episode of were expressed in percentages. diarrhoea in the family, only 50.7% had prepared Oral Rehydration Solution (ORS) at home. Regarding the Ethical consideration: Approval for the study was purpose of ORS in the treatment of diarrhea, only 50% obtained from the Institutional Ethics Committee. knew that ORS is used in correction of Personal information obtained during data collection was dehydration.(Table 3) 74.7% said that they will take the kept confidential. person to the hospital when the diarrhea is not responding to home treatment, while the others (25.3%) would rather RESULTS wait for the diarrhea to settle on its own. Regarding personal hygiene, only 40.7% of the respondents washed A total 150 households from Arumanai Panchayat area their hands with soap and water before eating food and were included in the study. Out of the 150 respondents, only 24% did it after defecation. (Table 4) 58(38.66%) were males and 92(61.3%) were females. The age of the study participants ranged from a minimum of Table 3: Perceived purpose of ORS in the treatment of 18 to a maximum of 70 years. Among the respondents, diarrhea 26.7% (40) believed microorganisms to be a cause of diarrhea, while 39 (26%) said diarrhea was caused by Purpose Frequency Percent poor sanitation.(Table 1) 88% believed that boiling renders the water safe for drinking purposes. Correction of 75 50 % Dehydration Table 1: Perceived cause of diarrhea among To cure diarrhea 39 26 % respondents Do not know 36 24 % Causes Frequency (%) Total 150 100 % Micro organisms 40 (26.7%) Poor sanitation 39 (26%) Indigestion 28 (18.7%) Table 4: Hand-washing Practices among Respondents

Eating spicy foods 11 (7.3%) Practices Frequency Percent Intestinal worms 8 (5.3%) Always washing hands before Yes 145 96.7 Unclean water 6 (4%) food Chemicals 2 (1.3%) No 5 3.3 Eating too much sweets 1 (0.7%) Before food, washing hands Water only 86 59.3 with# Do not know 15 (10%) Soap & 59 40.7 Total 150 (100%) water Always washing hands after Yes 146 97.3 defecation No 4 2.7 Table 2: Measures taken at home to treat a diarrheal After defecation, washing hands Water only 111 76 with@ episode Soap & 35 24 water Measures Frequency (%) Ensuring children wash their Yes 143 95.3 hands before food No 7 4.7 Plenty of water 77 (51.3%) # n=145 @ n=146 Other fluids like ginger or lime 51 (34%) black tea Half of the households (n=76, 50.7%) used covered well Ignore 13 (9%) as their source of drinking water, while 25 (16.7%) used uncovered wells. 31 households (20.7%) used panchayat Restrict food intake 9 (6%) pipe and 17 (11.3%) used bore wells. Pond water was Total 150 (100%) used as a source of drinking water by one respondent (0.6%). 146 respondents (97.3%) had a toilet at home and 132 (88%) had a septic tank at home. Among those More than half of the people (n=91, 60.7%) were of the houses with their own septic tank, only 74 (56%) of the opinion that diarrhea was fatal by itself. 74.7 % of the households had a septic tank at the proper distance of people responded that hand washing reduced the chance more than 50 feet. Majority of the households, i.e., 91.3% of diarrhea. stored drinking water in a closed vessel. 47.3% people dipped the glass into the container where as 52.7% pour When a member of the household suffers from diarrhea, out water from the container. 41.3% of people use colour 77 families (51.3%) make them take plenty of oral fluids as indicator of contamination of water while21.3% use and 34% follow other measures like taking black tea with odour to detect contamination. 219 Diarrheal Diseases and Drinking Water Usage. Sudhir Ben Nelson et.al. Click here for more articles: www.commedjournal.in National Journal of Research in Community Medicine. Vol.6. Issue 3. Jul.-Sep.-2017(217-222) ISSN - Print: 2277 – 1522, Online: 2277 – 3517

Table 5: Primary method used to prevent diseases respondents using physical characteristics alone to spread by unsafe water identify safe water in an intervention study by Freeman et al. in Krishnagiri district in 2007.14This may be due to the Methods Frequency Percent better literacy and socioeconomic conditions among the Boiling water 129 86 residents of Arumanai in our study. About 11% of the Using filtration/ purifiers 10 6.7 mothers in the KAP study by Sillah also identified unsafe 13 Preventing water source 4 2.7 water by the color of water alone. contamination Coming to management of diarrhea, in our study 51.3% Purification of drinking 7 4.6 water source of the people take plenty of oral fluids and 34% use other measures like taking black tea with lime and ginger syrup Total 150 100 as home remedies. In a KAP study conducted in Nepal in Among the household measures undertaken to prevent May 2009, 40% of the participants preferred to have diseases spread by unclean water, 86% (129 people) home treatment for diarrhea out of which 19% knew the boiled water used for drinking purposes. Filtration as a correct home treatment.15Among our study population means of purifying water was used by only 6.7% of the 50% of the people prepare ORS at home and 38.7% know study population.(Table 5)Among the 86% who boil that ORS is used for correcting dehydration. In the study water before drinking at home, 38% heated the water just conducted in Nepal only 8% knew how to properly until it begins to boil and only 27.3% boiled water for 10 prepare and use ORS.15 In another study conducted to minutes as it should be done ideally. Among the people assess mothers’ knowledge and practice of home care who use well water, 44% do not clean the well frequently. management of diarrhea in case of children less than 58.3% clean the well by removing dirt from the bottom, 5years in Nakuru, Kenya, 17.5% of the participants knew only 20.7% use chlorination for cleaning the well. Among that ORS was used in diarrhea and only 7.75% used the panchayat pipe users, 82.7% did not know how often it.16Sillah also reported only 20% mothers studied knew the water is chlorinated. the proper way of preparing ORS properly.13

DISCUSSION 74.7% of our study population would seek treatment only when home based measures did not reduce diarrhea. Only In our study it was found that 26.7% of the people 54% of mothers in an urban Delhi slum would seek believed microorganisms to be the cause for diarrhea, immediate treatment for diarrhea.17This is mostly due to while 26% thought that diarrhea was the result of poor perception of diarrhea as a less serious disease. Compared sanitation. A minority also thought that diarrhea was the to other studies our study population had better awareness result of other causes such as indigestion, unclean water about the use of ORS in diarrhea. The number of people and spicy food. A study by Banda et al. in a Harijan who prepared ORS at home during diarrhea is also more. colony of rural in 2007 found that villagers The two reasons for this could be the increased literacy associated diarrhea with ‘heat, consuming spicy food or rate in Tamil Nadu compared to Madhya Pradesh and eating mud’. Unsafe water was not attributed as a cause Delhi slums and the awareness programs conducted here for diarrhea.10Our findings also compare favourably with about diarrhea and its prevention and management. a KAP study conducted in 2011 on water handling and sanitation practices in Ichhwar and Astha block in In our study 96.7% of the participants always washed Madhya Pradesh, where 18% respondents in Ichhwar their hands before eating, while 39.3% used soap and block and 22% in Astha block thought that diarrhea was water. In Ichhwar block only 20% used soap and water, 11 caused by dirty water or food. A reason for this could be whereas in Astha block 22% used soap and the better literacy in our study population compared to water.11Similarly in our study 76% washed their hands Madhya Pradesh. Kuberan also reported germs as the after defaecation compared to 22% in Ichhwar block and major perceived cause of diarrhea at 72% followed by 54% in Astha block. This difference can be attributed to 12 poor hand hygiene (27%) and spicy foods at 31%. the scarcity of water in Madhya Pradesh compared to Tamil Nadu and also economic and cultural factors. In our study 60.7% of the participants thought that Kuberan et al also found that hand washing before food diarrhea is fatal by itself. In a KAP study conducted by (70%) was more common than hand washing after Famara Sillah among mothers about management of defecation (32%) in their study.12Another study by Kumar children with diarrhea, 92% thought that diarrhea was a 13 et al in Manipur showed hand washing with water was serious childhood illness. more commonly followed rather than washing with soap 18 Among the respondents in our study, 41.3% of people and water. Banda et al. showed regular hand washing tend to use color as indicator of contamination of water was followed only by 86% of children under 15 years of 10 while 21.3% used odor to detect the contamination of age in rural Chennai. water. This is much lower than the result of 95% of 220 Diarrheal Diseases and Drinking Water Usage. Sudhir Ben Nelson et.al. Click here for more articles: www.commedjournal.in National Journal of Research in Community Medicine. Vol.6. Issue 3. Jul.-Sep.-2017(217-222) ISSN - Print: 2277 – 1522, Online: 2277 – 3517

Our study revealed covered wells as the source of Pradesh 19.6% in Ichhwar block and 24% in Astha block drinking water in half of the households (50.7%), with used filtration as a method of water purification.12 Kumar uncovered wells (16.7%), piped water (20.7%) and bore et al reported 63% of respondents using filtration as a wells (11%) being the other major sources of drinking method of purification.15 water. Kuberan et al in Chennai found a higher dependence on piped water (42%) and bore wells (37%) CONCLUSION: This cross sectional study conducted in as the drinking water source, probably because the study Kanyakumari district of south India showed that was based in the city of Chennai.12Pachori in his study in knowledge about diarrheal disease is inconsistent, with rural Salem found that majority of the people (85%) some aspects known to a majority while only a minority depended on piped water system.19 knew about certain other aspects. Although the knowledge and use of ORS is better than what is seen in Most of the respondents in our study (97.3%) had toilets many studies done in India, it is still less than what is within their homes with 88% having their own septic expected for an area with such high literacy rate. All of tanks, whereas only a much lower number of people the households practice drinking water purification but (62.7%) had toilets within their household premises in boiling (the most common method used) is not done rural Salem.19 The Chennai study by Kuberan et al had properly by more than two thirds of the households. higher percentage of houses (75%) with their own Measures for safe storage and handling of drinking water toilets.12 Banda et al. in their study in a Harijan colony are comparatively better followed, but can be improved. found only 30% of the villagers had toilets in their homes, Proper hand hygiene is not adequate. Thus there is need of whom only 86% actually used these toilets with the for behaviour change communication with respect to others preferring open air defecation.10 This can be diarrheal disease prevention and safe water handling attributed to the lower socio educational status and practices. We specially recommend hands-on training on cultural practices of the Harijan community. proper method of boiling and on disinfection of household wells. Most of our study participants (91.3%) stored water in closed container. Lower percentages of 75% and 83% ACKNOWLEDGEMENTS were reported by Kuberan and Pachori respectively in their studies. This may be due to the higher educational We thank all the faculty of the Department of Community status of our respondents.12, 19In a KAP study conducted Medicine, Sree Mookambika Medical College for their in Karachi regarding drinking water handling before and encouragement and guidance. We thank the college after interventions, it was found that before intervention management for providing us the opportunity and the 96% used a closed container and after intervention 97.5% resources to conduct the study. We thank the field staffs used a closed container.20Among our participants 52.7% from our college and the government setup who assisted pour out water from the container, while 47.3% dipped us during data collection in the study area. glass into container to collect water from it. 97.5% dipped glass into the container before intervention, whereas after intervention only 35% did so.20The difference may be due to cultural difference among the two regions. DECLARATIONS

In our study, 87.3% always boil drinking water at home, Funding: Self but among them only 27.3% boil water for 10 minutes. The villagers of rural Salem also preferred boiling (45%) Conflict of interest: None for disinfecting water with only 39% using other methods.1924% of respondents in a post intervention REFERENCES study by Freeman et al. in Krishnagiri district in 2007 treat drinking water before use by boiling, while 21% use 1. WHO. Diarrhea: Why children are still dying other methods (cloth/ other filters, purifiers).14Only 21% and what can be done. UNICEF/ WHO; 2009. of villagers in rural Villupuram treated water by boiling 68 pages. while others (78.4%) did not use any method to treat 2. Forsberg BC, Petzold MG, Tomson G, water at all, as reported by Mittal et al.21 Thus, our Allebeck P. Diarrhea case management in findings show a better level of knowledge and practice low- amd middle- income countries- an regarding point of use disinfection and treatment of unfinished agenda. Bull World Health drinking water among the residents of Arumanai, most Organ.2007 Jan; 85(1): 42-48. probably due to better literacy and socioeconomic status. 3. Perappadan BS. Highest under 5 deaths in India. The Hindu (online). 2012 Sep 13 [cited In our study only 17.3% of the people filtered drinking on 2015 Jan 10] Available from: water at home. In the KAP study conducted in Madhya http://www.thehindu.com/todays-paper/tp- 221 Diarrheal Diseases and Drinking Water Usage. Sudhir Ben Nelson et.al. Click here for more articles: www.commedjournal.in National Journal of Research in Community Medicine. Vol.6. Issue 3. Jul.-Sep.-2017(217-222) ISSN - Print: 2277 – 1522, Online: 2277 – 3517

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222 Diarrheal Diseases and Drinking Water Usage. Sudhir Ben Nelson et.al. Click here for more articles: www.commedjournal.in